The uses of ambiguity

Ambiguity in clinical communication carries both risks and benefits.¹ It can cause anxiety and confusion or it can provide a source of expanded understanding and new ideas. While scientists usually seek certainty, clarity and the elimination of divergent shades of meaning, in clinical communication what is often required is the deliberate preservation of uncertainty, and in these cases ambiguity is the means by which this is generally achieved.

When, in the clinic, the diagnosis or likely outcome is unclear, when what happens next is, or we want it to remain, uncertain, we call on ambiguity. We use ambiguity when we want to keep open future possibilities, however remote. We make use of ambiguity when we try to understand someone who operates within a different system of beliefs or values. In these cases, we draw for new possibilities on the location and mobilisation of the gaps in language, of the spaces in which meaning is not fixed, in which words gesture toward things, ideas, emotions and experiences.²

We turn to ambiguity when we ourselves are struggling to understand, when we wish to give voice to novel or difficult ideas: for example, when we are engaging in complex discussions of an ethical or philosophical nature, such as when we are trying to discern the goals of treatment or to clarify an emotional response. In these cases, ambiguity is a rich resource, a powerful motor of meaning creation. By allowing us to move within the shadow world at the boundaries of sense it enables us to fashion ideas and thoughts that have never before been articulated. It is here a weapon for conquering new territory, for driving beyond the limits imposed by conventional experience to the silent territory just outside what has hitherto been said.

When I face someone whose choices do not completely make sense to me – for example, a man with a treatable condition who refuses treatment, a woman who continues to smoke despite life threatening lung disease, the son of a man about to die who demands to keep going, no matter what the cost – I seek a way to break through the curtain of unintelligibility. To achieve this, I need to suspend my own system, my own presuppositions and standards of truth and validity. I need to make contact on a different level, to listen in a different vein: I have to try to imagine what he or she is getting at. As the patient talks I try out images and possible meanings to see if they work. I construct in my mind a system of categories of functional principles or qualities instead of causal interactions between hard organs. The task is to find common ground, a place where we can share sense.

Somewhat like talking in poetry, I open myself to a suggestiveness and an allusiveness.³ In almost all cases, against the odds, despite the differences in background assumptions, philosophical dispositions and expressive styles, I am able to gain a sense of his or her experience and to piece together an understanding of the broader clinical context, and the uncertainties, fears and hopes that underlie it.

The ability to deploy ambiguity is part of the everyday competence of clinical medicine. In the complex settings that there arise many modalities of communication come into play, including the utilisation of the sources of ambiguity at the edge of propositional speech: those devices, rhetorical forms, figures and tropes generally eschewed by philosophers and scientists but embraced by poets and creative writers.⁴ There is in speech itself a peculiar relationship that is generated from inside it, not as part of a formal, logical deduction involving an interlocutor but with a singularity located outside the explicit subject of the exchange, a singularity that is not thematised by the speech is indirectly approached by it. Therefore, speech is not a solitary or impersonal exercise of a thought or a process of mediation among contested propositions: it is a shared adventure of creation and discovery.

Boundaries and limitations always remain. There is no exact or complete transmission of information unchanged between systems of meaning. However, there is in all communication a common making sense, a mutually enriching contact, an enhanced respect and understanding. The meaning that is produced, that actually emerges from the process of dialogue between discrepant discourses, is different from the pre-existing meanings embedded within each of them. This process is therefore not one of pure translation but of the actual generation of new meanings within the specific syntactical, semantic and pragmatic contexts of the distinct discursive unities.

The conversations that occur in the clinic involve careful listening and the careful fashioning of ideas, arguments and suggestions. Often the objective is not to achieve certainty but to avoid it. In this endeavour ambiguity is a powerful and fecund resource, at least when wielded with skill and care. It provides a way to resolve differences in sense, to maintain flexibility and openness in our expressions, to preserve hope and to construct new pathways forward. It is the means by which we enter into communication where the possibilities for doing so are most remote.

References:

1. A fuller version of this article can be found in: Komesaroff PA. “Uses and misuses of ambiguity”. Internal Medicine Journal 2005; 35: 632–633
2. Empson W. Seven Types of Ambiguity. UK: Pelican; 1965.
3. Deleuze G. Clinical Essays. Minneapolis: University of Minnesota Press; 1997.
4. Levinas E. Philosophical Essays. The Hague: Martinus-Nijhoff; 1990.